Within the first six months of the disaster that followed 2005's Hurricane Katrina, the Louisiana Department of Health and Hospitals reported that New Orleans had lost 80% of its psychiatrists (1). Pre-Katrina New Orleans had 196 psychiatrists for a population of 480,000, and as of August 2006—one year after the Katrina floods—there were reportedly 22 for a population of 240,000 (1,2,3). On April 24, 2006, the U.S. Health Resources and Services Administration designated New Orleans a health professional shortage area, with one psychiatrist for every 21,000 people (4). Currently there are approximately 65 psychiatrists listed in the New Orleans phone book, which includes the surrounding suburbs of about one million people (5). Although the situation has improved, the restoration of health care has been problematic and has affected the city's recovery (6). This Open Forum analyzes barriers to returning medical schools and health care providers to the city sooner and recommends procedures to apply in future disasters to mitigate the decimation of the health care infrastructure, such as what has occurred in New Orleans.
In the immediate aftermath of Hurricane Katrina, Louisiana State University (LSU)-New Orleans Psychiatry Residency reestablished its program infrastructure by setting up rotations in state hospitals and clinics in three main cities. Charity Hospital, the LSU medical school, and much of the public mental health infrastructure in the city were flooded. Baton Rouge became the medical school headquarters. Most of the displaced residents and faculty relocated there, and others went to state hospitals and clinics in Lafayette and Pineville (7).
I was residency director at the time, and the LSU Department of Psychiatry set up training rotations at other state hospitals. We reasoned that funding lines would be most secure and justified if faculty and residents relocated to hospitals and clinics in need because of an influx of displaced New Orleanians. Despite this rationale, federal lines of funding for academic institutions dictate that money follows the hospital, not the doctors and patients.
Furloughs at LSU began around November 2005. Furlough is a means of laying off employees with the condition that they can be rehired if funds become available. The school was hemorrhaging financially, and the dean indicated that anyone would be furloughed who was not a core faculty member—essential to the survival of the residency and the medical school—or not directly funded by outside private contracts. Despite the city's tremendous mental health care needs, the LSU Department of Psychiatry lost 40% of its mental health care staff to furlough or through resignations, and the remaining 60% were displaced from the city for up to 1.5 years post-Katrina (7). Other LSU and Tulane residencies also suffered significant cuts. Many private practitioners without a means of tapping transitional funds to help get their practices restarted took jobs in other communities.
Once the LSU departments integrated into other communities, there were no clear deadlines for their expected return to New Orleans. All employees hoped that the time of displacement would be short. There was also hope that federal or state funding would soon be allocated to fund clinicians as first responders, to be integrated into nonflooded private facilities or temporary facilities in and around New Orleans. However, it became increasingly clear that there was no mechanism for this to happen.
The communities to which residency departments and physicians were displaced had significant needs before Katrina, and the needs were amplified with the influx of the displaced population. These communities now wanted the displaced physicians to stay and offered them contracts to do so. Given the uncertainty of the city's recovery, significant financial insecurities, and the risk of further downsizing of faculty because of the lack of funding, the LSU Department of Psychiatry, like many of the school's residency departments, accepted some of these offers, thus incurring contract obligations and further impeding their return to New Orleans. Many displaced private psychiatrists also accepted offers largely because of the lack of secure funding to transition them back into the city in the face of concerns about the future of their practices in New Orleans.
Federal officials have stated that they provided Louisiana over $250 million for mental health care and substance abuse treatment after the storm (8). In hindsight, it appears that federal funds may have been available to facilitate a quicker return of needed health care providers to the city if an operational structure had been in place to activate the process. Instead, many physicians lingered in displaced communities until at some point they engaged new contracts and jobs.
Madamala and associates (9) evaluated factors in the nonreturn of 312 of about 6,000 displaced physicians. Using multivariate logistic regression, they found that the most significant factor for nonreturn was severe or complete damage to the workplace. The highest concern was the cost of rebuilding physicians' practices. From my experience and among my colleagues, economic concerns appeared to be a core issue for the nonreturn of psychiatrists, even when there was no damage to their workplace. Madamala and associates underscored the need in future disasters for quickly establishing financial incentives, low-interest loans, and grants for rebuilding physician practices. In addition, looking at the increased burden that uninsured patients impose on financially weakened practices, Madamala and associates underscored that health care services for underserved populations should be prioritized expeditiously and disaster-specific grants and loans should provide bridge funding for health and medical staff salaries for those caring for this population (9).
In August 2006, a full year after the storm, the state Office of Mental Health (OMH) opened its first inpatient psychiatric facility in the city, a 20-bed adult unit and a 15-bed child unit in the New Orleans Adolescent Hospital (NOAH), which was never flooded and had been operational prestorm. The beds might have been available sooner, but OMH had frozen NOAH's operating funds and funds for repairs from the Federal Emergency Management Agency (FEMA) could not be used for operating expenses (10,11).
Around the same time, LSU Department of Psychiatry initiated a contract for a consult-liaison service with Touro Infirmary, a private hospital that also did not flood. It took nearly a year to work out the transfer of federal residency funding stipends from the flooded Charity Hospital to the private hospitals so that LSU residents and faculty could work there. In the meantime, uninsured patients filled the private emergency rooms, resulting in millions of dollars of hospital losses and deterring private physicians even more from returning home (12,13).
These few new services in New Orleans allowed for the return of some LSU School of Medicine faculty and residents from Baton Rouge and Lafayette. In addition, the LSU Healthcare Service Division, which is the organization in charge of state charity hospitals, decided to restore the flooded University Hospital, including limited psychiatric services. As these public facilities and new contracts were established, it became increasingly obvious that the LSU School of Medicine could not keep faculty at other sites across the state and meet the recovery needs of the city and the LSU school. Therefore the LSU School of Medicine and the Department of Psychiatry gave notice of termination of contracts that it had established in Pineville while the faculty was displaced and working there.
This was a difficult situation, and psychiatrists' experience was typical of that of other New Orleans physicians, who found themselves in similar double-bind situations. The LSU Department of Psychiatry members wanted to return to their home community but had moved forward with new contracts, which created obligations. Also, although the other Louisiana communities were extraordinarily gracious to the displaced New Orleanians, it was hard for them not to feel used as a source of interim funding as contracts were terminated and the New Orleans health care providers pulled out. In January 2007, a full year and a half after Katrina, the last of the LSU psychiatry residents and faculty finally returned to New Orleans.
Certainly no plan can control for all the adverse consequences of a disaster the size of Katrina. However, every attempt should be made to analyze whether future disaster plans or policy changes could better manage the return of health providers to their communities to expedite recovery.
The Joint Commission has established hospital requirements for disaster preparedness, but the specific plans are left up to the hospitals and communities (14). The time to plan is before a disaster. Every level of authority has a responsibility in developing a plan, but because the local community knows its own region and risks, it should proactively engage state and federal agencies (15).
Officials should do all they can to develop a means of keeping health care professionals as close to their home city as possible postdisaster to facilitate their ability to rebuild their practices. This would require changing existing public-private funding boundaries. When New Orleans flooded, the Charity Hospital psychiatric patients were evacuated to Central Louisiana State Hospital in Pineville, which is a four-hour drive from New Orleans. Central was chosen because it is a public facility that can accommodate uninsured patients. But postdisaster, if funding followed the patient and not the hospital, patients in need of public assistance could be accommodated in private hospitals still operational in and surrounding the disaster community and the displaced physicians could integrate there.
After Katrina, some private hospitals were in operation and had the physical room to accommodate uninsured patients and their health care professionals. But in the chaos of the postdisaster period, these kinds of partnerships could not be forged. Procedures and policies for these kinds of arrangements need to be established predisaster. Recommendations for doing so are outlined below.
Activate disaster hospitals and local first responders
Postdisaster, all operational hospitals as close to the metropolitan area as possible should be converted to disaster hospitals that treat public and private patients, and funding should follow the patient.
In addition, a postdisaster mechanism is needed where local physicians, working in public or private sectors, can receive pay to provide first-responder services. This would provide a bridge to help them return and reestablish their practices. Displaced New Orleans psychiatrists voluntarily assisted in shelters in areas where they were displaced, but they would have and could have returned to help with first-responder services in the city if such a mechanism had been in place. First responders from other areas were deeply appreciated, but after limited interventions, there were no psychiatrists to whom to refer patients for continued treatment.
Providing funding to pay local health care providers to treat patients would require changes in the Stafford Disaster Relief and Emergency Assistance Act that governs how FEMA reimburses disaster areas. The Stafford Act allows funds to be used to recruit outside health care providers to care for immediate crisis needs. However, it does not allow funds to be used to bring existing health care providers back into the city where they can address crisis needs and reestablish long-term, ongoing health care treatments and infrastructure (16,17,18). For example, Louisiana Spirit, a federally funded organization that addressed first-responder mental health counseling needs postdisaster, was not allowed to treat patients; those providers could perform only crisis stabilization services (Rigamer E, personal communication, January 2009). The Stafford Act should be amended to include hiring psychiatrists in the disaster area to receive referrals for treatment from the outreach workers. A recent report by the Center for Catastrophe Preparedness and Response at New York University recommends changes to the Stafford Act that include funding public employees, including physicians, at least for a limited time postdisaster, to prevent the bankruptcy of city government while it is struggling to fund its workers (17,18).
The cost of Katrina has been estimated at greater than $100 billion (19). The bureaucracy of accessing federal funds was difficult, and often available funds were not delivered to their mark fast enough. In hindsight, sufficient bridging funds could likely have been available to pay the local health care professionals as first responders and mental health care providers if a clear plan had been in place predisaster. According to federal officials, over $40 million of federal funding allocated for mental health had not been used by the summer of 2007, and some funds had to be returned (8).
In 2007, two years after the Katrina disaster, Mike Leavitt, the U.S. Secretary of Health and Human Services, dedicated $100 million for the recruitment of health care professionals to New Orleans (20). However, rather than attempting to recruit new providers to a postdisaster region, a better approach would have been to provide assistance to local providers who have roots in and allegiance to a community. Giving a $150,000, one-year guarantee to all 196 of the pre-Katrina New Orleans psychiatrists would have cost $29 million without any other source of patient billing. Currently there are many patients with insurance in need of services in New Orleans, and private practitioners' practices are filled, so this "guarantee" would have been offset significantly by viable billing.
When it is estimated that twice as many mental health professionals are needed in the face of a disaster (21), it is clear that predisaster plans and policies must be created to prevent furloughs or long-term displacement of health care providers.
Establish FEMA independent-contract health care workers
In the postdisaster period, all health care professionals—working in the public or private sector—should be offered the opportunity to register with FEMA as first-responder, independent-contract agents. They would be encouraged to bill for services to patients with insurance but would be given a transitional salary guarantee as they attend to first-response needs and reestablish their practices. FEMA and SAMHSA, perhaps through their funded disaster organizations such as Louisiana Spirit, would direct these first responders to local disaster hospitals and clinics.
In addition, medical villages should be established immediately in the home community. Optimally, these villages should include housing for community providers and their families, with schools, playgrounds, and other basic public facilities.
An assessment of existing community health care infrastructure in the disaster region should be made as soon as possible after a disaster. Operational health care infrastructure should be stabilized and possibly expanded to accommodate the public and private health care needs of the community.
There were a number of barriers to shoring up the flooded charity hospitals, which some say could have been reopened. Charity Hospital had teetered on the edge of losing its accreditation for some time because of its antiquated structure, and politicians and administrators have been accused of using the storm as an opportunity to build a new hospital (22). There are ongoing debates about whether the state should have performed repairs and reopened Charity at least temporarily while plans for a new hospital are actualized (23). In the meantime, approximately a year after Katrina, the state reopened about 200 public-charity general hospital beds at University Hospital (Charity Hospital had 450 beds), which is helping to address health care needs of indigent patients. Nevertheless, future disaster plans that would allow for money to follow the patient would provide the private sector the financial means of caring for indigent patients until public infrastructure can be reestablished.
Many other important factors contributed to the slow recovery of the health care infrastructure in New Orleans after Katrina and must be addressed. These include ensuring a means of quickly delivering needed medications to patients. In addition, the bureaucratic process must be streamlined for accessing available grant and loan monies. Also, although complex and difficult to describe, many barriers were created by the imperfect health care systems and layers of bureaucratic territorialism and fiefdoms intrinsic in Louisiana and New Orleans, which thwarted collaborative work in the poststorm crisis. When such barriers were surpassed by dedicated individuals with perseverance, the triumphs were often poignant.
No one wants to think about a possible disaster in their home community, but most accept the fact that future disasters are inevitable. In the New Orleans recovery, the continued lack of health care personnel is one of the greatest ongoing challenges. Health care professionals were displaced from the city for prolonged periods, and some evacuated, never to return. Future disaster plans should include legislation that facilitates funding and policies aimed at returning health care professionals and infrastructure to the affected region sooner to mitigate the level of decimation that the New Orleans' health care system has witnessed (1,2,24,25).